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Date:

Name and Address of Doctor or Office:

Name and Address of Partner:

Dr. Ron Manoni12 Cawdor Burn RoadBrookfield CT 06804

1.1 In order to comply with HIPAA and state standards in maintaining confidentiality of protected health information the above parties agree to enter into the following:

1.2 Each party will transmit and receive information either directly or indirectly through a third party. Both parties will negotiate the cost of transmitting and receiving data in a separate agreement.

1.3 If a third party is utilized, once this agreement is executed, then the third party shall be responsible for the confidentiality of all protected health information. In any ancillary agreement both parties agree that this agreement will supersede any language in responsibility for transmitting protected health information.

1.4 Each party shall be responsible for the security and operation of their own system and protected health information including, but not limited to all federal standards required under HIPAA and it is agreed upon that neither party will be responsible for the other party’s system or failure to maintain confidentiality. Each party further agrees to indemnify the other party for any and all costs, including but not limited to legal expenses, ancillary expenses or consequential damages should the other party be found liable for breach of integrity or confidentiality that is the fault of the offending party.

1.5 Both parties will mutually agree upon adopting a signature standard as well as exchanging the names of staff that is authorization to sign.

1.6 Upon satisfactorily receipt of the documents, the receiving party must render a report to the sender verifying receipt.

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1.7 This document shall remain in effect until terminated by either party with a minimum of 30 days written notice with proof of receipt of notice (certified mail of fax receipt)1.8 This document shall remain in effect and it is agreed to unless the failure is by an act of God and therefore beyond the control of either party. Each party has read this agreement and agrees to enter into this chain of trust agreement effective on the above date.For: [facility or doctor]